Instructions:

1. Please fill the form in BLOCK LETTERS and (*) MARKED Fields are Mandatory.
2. Inconsistent/incomplete applications are liable to be rejected.
3. Attestation of documents by any: Gazetted Officer OR Bank Manager OR Company Secretary OR Post Master OR
present originals to our Registration Authority for verification & attestation.
4. All subscribers are advised to read Certification Practice Statement and Subscriber agreement eMudhra available at www.e-mudhra.com
5. At Par Cheque / Demand Draft to be drawn in favour of eMudhra Consumer Services Ltd.
6.For Class III Digital Signatures In Person Verification of the applicant is mandatory

APPLICATION FOR DIGITAL SIGNATURE CERTIFICATE - FOR ORGANISATION
Affix
recent passport
photograph of the
applicant duly
signed across
1A. CERTIFICATE CLASS* 1B. CERTIFICATE TYPE* 3. USB TOKEN* 2. CERTIFICATE VALIDITY*
1 Year
2 Years
Required
Not Required
Signature Class 2 Gold Organisation
Class 3 Platinum Organisation
APPLICANT DETAILS* (As per applicant's valid ID Proof at Sl. No. 11below)
6. Gender:* Male Female 7. Nationality
4. Name:* Mr./Ms./Dr.
5. Date of Birth:*
8. Father/Spouses Name
Y Y Y Y M M
D D
F I R S T N A M E M I D D L E N A M E L A S T N A M E
IDENTIFICATION DETAILS*
12. a) PAN of the Applicant:
Encryption
ORGANISATION DETAILS* (Door No., Name of the premises, Road, Area, City, State and Pin Code needs to be filled)
10. Organisation Details: * Corporate Office Head Office Registered Office Branch Office
Organisation Name
Registration Number
Date of Incorporation / Proprietorship
Commencement / Partnership Agreement
Corporate Website (URL
PAN No. of Organisation* Attach photo copy)
Address :
Pincode City State
Telephone No. (e.g. +91-80-23333333) Mobile No. (e.g. + 91-9999999999)
Fax No. (e.g. +91-80-23333333)
Organisations Bank Account Details: *
Bank Name
Branch Name & Place
Account Type
Account Number
Savings Current
12. b) Valid Identity Documents : * Passport Copy of Driving License PAN card Post Office ID Card
Bank Account Passbook containing the Photograph and signed by an individual with attestation by the concerned Bank official
Photo ID Card issued by the Ministry of Home Affairs of Centre/State Government Document ID No.
Any Government issued photo ID Card bearing the signatures of the individual
11. E-Mail ID:* (Valid and active E-mail ID to be included in the Digital Signature Certificate)
I N D I A N
9. Residential Status* Resident
Department
Version 1.3 CONFIDENTIAL
Application ID Number (For office use only): (For Signature Application only)
(For Encryption Application only)
Aadhaar Card
PAYMENT DETAILS*
13. Mode of Payment *
Online Payment Details
Account Type
Amount Rs.
Online Cheque/DD
Cheque/DD Payment Details
Bank Name
Transaction/Reference No.
Date
Account Type
Amount Rs.
Bank & Branch Name
Cheque /DD No.
Date
DECLARATION
I hereby agree that I have read and understood the provisions of eMudhra Certification Practice Statement (CPS) and the subscriber agreement and will abide by the same. The information
provided in this Digital Signature Certificate request form is true and correct to the best of my knowledge and I accept publishing my certificate information in eMudhra repository.
Place :
Date :
Signature of the Applicant
Name of the Applicant :
Office Seal and Stamp
UNDER CHECK LIST OF ORGANISATION DOCUMENTS TO BE SUBMITTED ALONG WITH THE APPLICATION*
a. ID proof of applicant as selected in S.No 12
b. True copy of any one (attested by Company Secretary OR Director OR Partner of the Organisation as applicable)
Certificate of Incorporation Memorandum of Association Regd. Partnership Deed Valid Business License
c. True copy of any one (attested by Company Secretary OR Director OR Partner of the Organisation as applicable)
Annual Report Latest Income Tax Return Latest Organisation Bank details from the Bank Statement of Income issued by Chartered Accountant
d. Attested Copy of the Organisation PAN Card
e. Authorization letter in favour of the certificate applicant from the Organisation as per format below
f. List of Partners/Members/Directors with their complete name and address details
To,
eMudhra Consumer Services Limited,
3rd Floor, Sai Arcade, 56 Outer Ring Road,
Deverabeesanahalli, Opp Intel, Bangalore 560103
Phone : +91 80 4336 0000
Date : D D M M Y Y Y Y
Dear Sir,
Sub : Authorisation letter for obtaining Digital Signature Certificate.
This is certify that Mr./Mrs./Miss. ________________________________ (Certificate applicant) has provided correct information in the Application form for issue of Digital Signature
Certificate to the best of my knowledge and belief vide application form dated DD-MM-YYYY. I hereby authorize him/her, on behalf of our Organisation to apply for obtaining the following
Class of Digital Signature Certificate issued by e-Mudhra.
Class 2 Gold Organisation
Signature :
Name :
Designation :
Department :
Office Seal and Stamp :
CONTACT DETAILS
TO BE FILLED BY RA OFFICE ONLY*
I declare that the applicant has provided correct information in this application form. I have checked and verified the application form and supporting documents.
RA Name :
Signature :
Place :
Date :
RA Seal & Stamp
Class 3 Platinum Organisation Class 3 Device / Server
Details of Executive Authorizing the Applicants :
AUTHORISATION LETTER FORMAT*
eMudhra Consumer Services Limited, 3
rd
Floor, Sai Arcade, 56 Outer Ring Road, Deverabeesanahalli, Opp Intel, Bangalore 560 103. Karnataka
Phone : +91 80 4336 0000 Fax : +91 80 4227 5306 Email : info@e-Mudhra.com Website: www.e-Mudhra.com
Version 1.3 CONFIDENTIAL
I hereby consent to revoke my Digital Signature Certificate, if physical copy of the Digital Signature Certificate Application along with the supporting documents are not received by
eMudhra CA within 15 days of issuance of Digital Signature Certificate.